read part one first. That was among my most popular entries ever. If you are finding this useful, your fellow students probably will too – why not share it with them? It’s part of a series of blogs on the current nursing scene, especially for new nurses and nursing students. I also invite you to subscribe!

There are a few common scenarios in nursing education. These take place at clinical.

a) at the end of the clinical day the instructor is making rounds after the students have left, and one staff nurse says “your student in rm 438 did not give a bath, did not report the vital signs, and omitted a med that was due at noon” (this always puts the faculty on the defensive, in case you wanna know)

b) the teacher and the student are lined up at the med cart about to give a heart pill, and the student did not check the Apical Pulse or take the Blood Pressure. Or maybe it’s a stool softener and the student has no idea when the last time the patient moved their bowels. or maybe it’s lasix and the student doesn’t know what the K+ was.

c) the student takes report from the night nurse, but doesn’t write anything down and can’t recall what was said when the faculty asks what the night nurse had to say about the patient.

I can think of more; but what I want you to ask yourself right now is, have any of them happened to you?

The reaction to all of the above, is to pass the feedback along to the student, and maybe to put the student on a written warning, which is logical. After all, we’re about doing our best, here. If the student gets enough written warnings, they learn to be afraid of making a mistake, (which is good); but they also learn to dislike clinical, (which is bad. clinical is the reason we are here). And the faculty wonders why this happens over and over again……. a new faculty person is also on a learning curve, and when you are new at teaching, y0u may not have the tools to develop a better approach. It’s easy to blame the students….

Pro-Active? or Re-Active?

Simply dumping on the student is usually a sign of a faculty member who did not see the value of teaching organizational skills to their crew. It’s the easy way out – a way for the faculty to shift blame. It’s Re-active – closing the barn door after the horse has left. Both the student and the faculty will benefit from a pro-active approach – oh, and so will the patient :-)

You may find this difficult to believe, but to use a Road Map, also known as the Nurses Brain, is a pro-active tool in preventing all of these things from occurring. There is no situation so chaotic that a Brain can’t bring some order when it is applied.

Part One dealt with how to set up a Brain.

I got a terrific reply to Part One from Dan Keller, a nurse who has a Blog Site Titled Nurses Get it Done. Dan was very humble about his site, but I was happy to find it. Go there, and you can find more examples of a Nurse’s Brain. He also has info about an iPhone app that can be used to keep track of all the little pile of details that a nurse has to deal with.

So – how to become pro-active vs Re-active?

For me as a faculty, I require that the student bring a Road Map to clinical and show it at the beginning of the clinical day. Every time I speak with that student during the day, we pull it out and go over it. Every time a staff nurse gives report, the student also writes down every tidbit of data that has been shared, and the student has to determine whether a followup response is required.

I got another email from a nurse who said she wants to make sure the student can name what’s going on with their patient “and that’s the most important.” Fair enough. She probably works with seniors; and also, when you make a Road Map every day, you can add reminders to yourself to schedule an actual time to physically assess the most important feautures of your patient’s illness event. In addition to the Road Map, we also require a Concept Map, an eight-column medication form etc – if I made it sound like we didn’t, or that I never bring up the more sophisticated concepts of patho, don’t worry – we do those things. The time to start using a Brain is Fundamentals – from the beginning of hospital practice.

Accountability

One of the mantras is: ” we don’t have to do every single thing we planned out for the Road Map, but if we can’t, our responsibility is to tell the staff nurse with sufficient time so that they can do it before it’s too late”

If the whole crew is using a road map, it allows the clinical groups to create synergy, and help each other by scheduling some tasks for the larger group – such as doing incontinence care for a 400-lb helpless patient, for example, which would require more than just one person. I worked at a 400-bed hospital in Bangor, Maine, where the nursing crew routinely delivered care for patients with life-threatening morbid obesity – that group of nurses were a marvel of teamwork. This eliminates a lot of mini-crisis from the day.

Buying the morning paper?

The next thing that can happen with a well-planned Road Map is effective chaining of tasks. Now, women are much better at chaining tasks than guys are ( hate to sound sexist and I don’t know why this is the case, but I think it’s true). True story: if I was going to get the morning paper from the corner store, I would go and get it. But, if I mentioned to my wife I was going down the street for that purpose, she would say “Oh, and we also need toilet paper and would you get some bread and milk too?” My wife was also a nurse. Nurses become excellent at “chaining” tasks.

Chaining….

an example of chaining for the Road Map would take place after you observed that it was an hour after breakfast and your patient was incontinent of stool. Obviously, you are going to help them with personal hygiene; so you might as well do their whole bath at that time, and you will bring in the supplies to do a sacral dressing change if they have a sacral wound, and you can also check their heels at the same time, do range-of-motion and repositionthem. six tasks with just one trip into the room.

We are on a quest for excellence in nursing, not just personal excellence but excellent patient outcomes in team care. And I can’t speak highly enough of the books by Atul Gawande, MD. His book, the Checklist Manifesto, is about the ways that teams improve, and he has lots of practical examples and a great way to express how to approach the idea of improving your practice day-to-day.

I can’t really add much beyond what the reviews have already said, but here is a start, from Amazon.

Amazon Exclusive: Malcolm Gladwell Reviews The Checklist ManifestoMalcolm Gladwell was named one of TIME magazine’s 100 Most Influential People of 2005. He is most recently the author of What the Dog Saw (a collection of his writing from The New Yorker) as well as the New York Times bestsellers Outliers, The Tipping Point, and Blink. Read his exclusive Amazon guest review of The Checklist Manifesto:

Over the past decade, through his writing in The New Yorker magazine and his books Complications and Better, Atul Gawande has made a name for himself as a writer of exquisitely crafted meditations on the problems and challenges of modern medicine. His latest book, The Checklist Manifesto, begins on familiar ground, with his experiences as a surgeon. But before long it becomes clear that he is really interested in a problem that afflicts virtually every aspect of the modern world–and that is how professionals deal with the increasing complexity of their responsibilities. It has been years since I read a book so powerful and so thought-provoking.

Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.

The danger, in a review as short as this, is that it makes Gawande’s book seem narrow in focus or prosaic in its conclusions. It is neither. Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious. Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help. –Malcolm Gladwell

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